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cannot explain all features of volume regulation and sodium reabsorption in the nephrotic syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">3&#8211;5</span></a> Children with edema associated with idiopathic NS &#40;INS&#41; do not commonly have intravascular volume depletion&#59; actually several studies suggest that children with INS may have normal or even increased intravascular pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6&#44;7</span></a> The overfill hypothesis now suggests that edema is a result of a primary renal defect in sodium excretion that is independent of low oncotic pressure and is responsible for primary extracellular volume expansion&#44; which leads to secondary leakage of fluid toward the interstitium&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">While the mechanism of edema is a theoretical topic of discussion&#44; understanding the intravascular volume status of the patients accurately is a crucial issue while planning the treatment of edema&#46; However&#44; a significant issue in the consideration of this problem is the lack of a gold standard for the assessment of intravascular volume&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">10</span></a> Several noninvasive techniques for the assessment of hydration status exist&#46; Monitoring of relative blood volume changes&#44; inferior vena cava diameter &#40;IVCD&#41; measurements and biochemical markers such as atrial atriuretic peptide &#40;ANP&#41;&#44; brain natriuretic peptide &#40;BNP&#41; are indirect methods&#44; which provide information about the intravascular filling&#46; Although dilution methods are accepted as the most appropriate standards for fluid volume determination&#44; they cannot be applied in routine clinical practice due to the patient availability for many hours and time-consuming assays of blood samples&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10&#8211;12</span></a> In recent years&#44; Bioelectrical impedance analysis &#40;BIA&#41; has found a place in the literature as a practical method for measuring body fluids particularly for patients on hemodialysis due to its advantages such as ease of application&#44; non-invasiveness&#44; and reproducibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">12&#8211;17</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The present study aimed to determine the volume status using multifrequency BIA&#44; NT-proBNP levels&#44; IVC&#44; LAD measurements to examine the relationship between various volume indicators and to investigate the utility of BIA in evaluating the volume status in children with INS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Nineteen children &#40;11 males&#44; 8 females&#41; with NS at debut or relapse admitted to our nephrology unit were prospectively studied from September 2012 to October 2013&#46; 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per International Study of Kidney Disease in Children regimen<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">18</span></a> &#40;started after routine workup for new NS patients and immediately upon admission in relapsed NS patients&#41;&#46; Patients were excluded from the study if they met any of the following criteria&#58; established cardiovascular disease&#44; evidence of secondary NS and specific glomerulonephritis&#44; usage of steroids or immunosuppressive drugs during the previous six months&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Twenty-five age and sex matched healthy volunteers served as the control group&#46; These subjects had normal blood pressure &#40;BP&#41;&#44; no clinical electrocardiographic &#40;ECG&#41; or echocardiographic evidence of cardiovascular disease&#44; and no evidence of pulmonary disease&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study design</span><p id="par0030" class="elsevierStylePara elsevierViewall">A complete review was carried out for each patient which included the patient&#39;s past and family history&#44; physical examination and data such as gender&#44; age&#44; height&#44; weight&#44; blood pressure &#40;BP&#41; on admission&#46; Their clinical edema findings were appraised by the same pediatric nephrologist&#46; Hypertension was defined as blood pressure of more than the 95th percentile for gender&#44; age and height&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">19</span></a> Tachycardia was defined as a heart rate above the upper heart rate limit adjusted for age&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Biochemistry analyses&#44; serum NT-proBNP&#44; anthropometric and BP measurements&#44; BIA&#44; and IVC&#44; left atrial diameter by echocardiography were performed at baseline in all participants&#46; Blood and urine samples were collected for the laboratory assessments listed in the study protocol&#46; Then&#44; the serum samples were stored at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C for NT-proBNP measurements&#46; Prednisolone treatment was initiated after the first evaluation of the patients&#46; Physical examination&#44; laboratory assessments&#44; BIA&#44; echocardiographic evaluation and NT- proBNP measurements were repeated during the remission period in the patients group&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Control data were used to compare the results of laboratory assessments&#44; BIA&#44; cardiovascular &#40;IVC and left atrial diameter&#41; and NT-proBNP measurements&#46; This study was approved by the ethics committee of the Medical Faculty of Ondokuz Mayis University&#46; Informed assent and consent were obtained from their parents before the study began&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">According to the study group&#44; the patients were evaluated into two categories&#58; Debut or relapse of NS in admission &#40;group I&#41; and in remission after treatment &#40;group II&#41;&#46; Healthy volunteers served as the control group &#40;group III&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Blood and urine samples</span><p id="par0050" class="elsevierStylePara elsevierViewall">Blood and urine samples were collected at debut or relapse of NS and when stable remission &#40;10&#8211;14 days after initiation of treatment&#41; was achieved&#46; The medication &#40;steroids&#41; was continued in unchanged dosages during the 10&#8211;14 days of study&#46; Blood samples for measurements of serum creatinine&#44; albumin&#44; sodium and urine analysis of creatinine&#44; sodium&#44; protein excretion from spot urine samples were analyzed at the Department of Clinical Biochemistry using standard procedures&#46; Fractional excretion of sodium &#40;FENa&#44; &#37;&#41; was calculated by on spot urine tests by the formula&#59; serum aldosterone levels and plasma renin activity were determined by using Beckman Coulter RIA &#40;Radioimmunoassay&#41; kits with a Gamma counter device &#40;ISO Data Multiwell Gamma Counter&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">For determination of NT-proBNP&#44; venous blood samples were collected in biochemistry tubes without anticoagulant and allowed to coagulate&#46; The samples were centrifuged &#40;4000<span class="elsevierStyleHsp" style=""></span>rpm for 5<span class="elsevierStyleHsp" style=""></span>min at &#43;4<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; and the serum frozen at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C until analysis&#46; The kits and serum samples were allowed to reach room temperature &#40;&#43;25<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; before the measurement&#46; Serum NT-proBNP levels were measured by ELFA &#40;enzyme-linked fluorescent assay&#41; method using a VIDAS PC device &#40;bioMERIEUX&#44; France&#41; with commercial NT-proBNP kits &#40;VIDAS&#38;NT-proBNP&#44; bioMERIEUX&#44; France&#41; at the Investigational Laboratory of Ondokuz Mayis University School of Medicine&#46; The results were expressed as pg&#47;mL&#46; The analytical measurement reference range of the NT-proBNP kit was 20&#8211;25&#44;000<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#46; The measurement was performed as per the procedure of the manufacturer&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Bioimpedance measurement</span><p id="par0060" class="elsevierStylePara elsevierViewall">Two bioimpedance analysis &#40;BIA&#41; are currently available for use in clinical practice&#58; single-frequency bioimpedance analysis and multifrequency bioimpedance spectroscopy &#40;BIS&#41;&#46; Single-frequency BIA&#44; measures whole body impedance using one electrical current with a frequency of 50<span class="elsevierStyleHsp" style=""></span>kHz&#46; Therefore this cannot differentiate between extracellular and total body fluid resistances because this frequency of electrical currents do not pass cell membranes&#46; The multifrequency bioimpedance spectroscopy &#40;BIS&#41; depends on a different electrical model&#46; ECW and TBW resistances are determined using multiple imperceptible currents of varying frequencies and these water volumes are calculated from the respective impedances&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">20</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We applied the Body Composition Monitor &#40;BCM&#44; Fresenius Medical Care&#41; using multi-frequency BIS in order to assess the hydration status&#46; Four electrodes were placed on each side on the dorsal surfaces of hands and feet of the supine patients&#46; Two electrodes were dorsally placed in the metacarpophalangeal articulations and in the carpus of the hand respectively&#46; The pair on the foot was located in the metatarsophalangeal and in the ankle articulation&#46; Patients were connected to the device with these electrodes and measurements completed in 1&#8211;4<span class="elsevierStyleHsp" style=""></span>min after entering gender&#44; height &#40;in cm&#41;&#44; body weight &#40;in kilograms&#41;&#44; and blood pressure &#40;systolic and diastolic mm Hg&#41; data for each patient&#46; Body composition analysis was performed by using Fluid Management Tool version 3&#46;2&#46;11 software&#46; In cases with inadequate data quality&#44; the measurements were repeated by changing the electrodes&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Results of measurements included that of overhydration &#40;OH&#41;&#44; total body water &#40;TBW&#41;&#44; extracellular water &#40;ECW&#41;&#44; intracellular water &#40;ICW&#41;&#44; body mass index &#40;BMI&#41;&#46; Bioimpedance spectroscopy &#40;BIS&#41; uses physiological modeling and mixture equations &#40;Cole&#8211;Cole plot and Hanai formulae&#41; to first determine the electrical resistance of ECW and ICW and then calculate the volumes of these respective compartments&#46; This is essential for identification of OH&#46; The BCM uses the BIS technique&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">20</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The BCM states the body weight in means of lean tissue mass &#40;LTM &#8211; mainly muscle&#41;&#44; adipose tissue mass &#40;ATM &#8211; mainly fat&#41; and overhydration &#40;OH&#41;&#46; OH is almost 100&#37; ECW&#44; whereas the water of LTM and ATM consist differing ratio of ECW and ICW in addition to solid components&#46; As the extracellular hydration of LTM and ATM is known&#44; the estimated &#8220;normal&#8221; volume of ECW of these tissues can be calculated&#46; The difference between &#8220;normal&#8221; ECW and measured ECW is the excess fluid&#44; OH&#46; Reference ranges are available for OH&#44; lean tissue index &#40;LTI&#41;&#44; fat tissue index &#40;FTI&#41; and extracellular&#47;intracellular &#40;E&#47;I&#41; ratio&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a> These ranges simplify identification of abnormal conditions by evaluating the patient&#39;s results to the reference population&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Echocardiographic measurements</span><p id="par0080" class="elsevierStylePara elsevierViewall">Echocardiographic evaluations were performed at the time of BIA investigation by the same pediatric cardiologist&#44; using the &#8220;Toshibo Aplio 770s Echocardiography System&#8221; with 3&#46;5 and 5&#46;5<span class="elsevierStyleHsp" style=""></span>MHz probes as appropriate for age after resting &#40;for 10&#8211;30<span class="elsevierStyleHsp" style=""></span>minutes&#41; in the supine position&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All examinations were measured IVCD was measured from subxiphoidal long axis position in 2<span class="elsevierStyleHsp" style=""></span>cm to its junction to right atrium before the p wave in the electrocardiogram&#46; The maximum diameter in expiration and the minimum diameter in deep inspiration were measured and indexed for body surface area &#40;BSA&#41;&#46; Left atrium diameter &#40;LAD&#41; was measured at the parasternal position&#46; LAD was determined as diameter of left atrium &#40;mm&#41;&#47;body surface area &#40;m<span class="elsevierStyleSup">2</span>&#41;&#46; The patients were scanned during debut or relaps NS and at remission periods&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical evaluation</span><p id="par0090" class="elsevierStylePara elsevierViewall">Statistical analyses were performed using &#8220;SPSS for Windows<span class="elsevierStyleSup">&#169;</span> 15&#46;0&#8221; &#40;Statistical Program in Social Sciences&#41; package software&#46; Data are presented as mean and standard deviation &#40;SD&#41; or as median and ranges &#40;minimum&#8211;maximum&#41; according to their distribution&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">For the comparisons between the patient group and the control group&#44; the independent samples <span class="elsevierStyleItalic">t</span>-test was used for the parameters with normal distribution and the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test was used for the parameters with non-normal distribution&#46; The pre- and post-treatment data of the patient group were compared using the paired samples <span class="elsevierStyleItalic">t</span>-test or the Wilcoxon rank-sum test&#46; To determine the significance and strength of associations&#44; we used the Pearson&#39;s correlation coefficient <span class="elsevierStyleItalic">r</span> for analyses of associations between continuous variables and Spearman rank for non-parametric variables&#46; The <span class="elsevierStyleItalic">p</span> values below 0&#46;05 were considered as statistically significant&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Baseline demographic and clinical and biochemical characteristics of the study population</span><p id="par0100" class="elsevierStylePara elsevierViewall">A total of 19 patients with debut &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#41; or relapse &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41; of NS and 25 healthy children were enrolled in the study&#46; Demographic and clinical data of the study groups are reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; In the present study&#44; 17 patients were diagnosed with INS based on the clinical and laboratory findings&#44; and steroid therapy was initiated without obtaining kidney biopsy&#46; The diagnosis of MCNS was supported after biopsy in one patient who remained refractory to steroid therapy&#46; Two patients older than 10 years were biopsied and then steroid treatment was started with the diagnosis of MCNS&#46; 3 patients were excluded from group II because of refractory to steroid therapy&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The mean &#40;&#177;SD&#41; age of the patient and control populations were similar &#40;5&#46; 1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;53 vs&#46; 5&#46;98<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;84 years&#44; respectively&#41; and according to gender distribution&#44; there were 8 girls and 11 boys in NS group and 16 girls and 9 boys in control group&#46; There were no significant differences in age&#44; gender&#44; weight&#44; height or BSA between the patient and control groups&#46; The median BMI was significantly higher in group I than in group III &#91;18&#46;3 &#40;15&#46;6&#8211;22&#46;7&#41; vs&#46; 16&#46;7 &#40;13&#46;7&#8211;24&#46;2&#41; kg&#47;m<span class="elsevierStyleSup">2</span>&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#93;&#46; There was no difference in the BMI values between group I and group II &#40;data was shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The remaining comparison of the patients with NS and control group are given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; None of the patients had clinical signs of hypovolemia&#44; such as tachycardia&#44; pallor or abdominal pain&#46; Eight &#40;42&#46;1&#37;&#41; were hypertensive at the time of investigation&#46; Compared with healthy controls&#44; group I had significantly higher systolic and diastolic blood pressure but not significant in the group I and the group II &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; In addition to the significantly higher proteinuria and lower serum albumin concentrations&#44; patients had lower FE<span class="elsevierStyleInf">Na</span> levels&#44; the lowest in the group I&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the laboratory measurements&#44; including serum albumin&#44; spot urine&#47;creatinine&#44; FE<span class="elsevierStyleInf">Na</span> serum renin and aldosterone levels in patients and controls&#46; All the laboratory measurements were statistically significant different in group I than in group III&#59; however&#44; there was no difference in serum renin and aldosterone levels among the groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Comparison between volume status assessment methods</span><p id="par0110" class="elsevierStylePara elsevierViewall">Patients&#8217; and healthy controls volume status were investigated at the same time using echocardiographically derived parameters &#40;IVC&#41;&#44; cardiac biomarkers &#40;NT-proBNP&#41; and BIA parameters&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Group I patients&#8217; had significantly higher NT-proBNP value in comparison to the group II &#40;114 &#40;20&#8211;1031&#41; vs&#46; 30 &#40;20&#8211;514&#41; pg&#47;mL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; and group III &#40;114 &#40;20&#8211;1031&#41; vs&#46; 29 &#40;20&#8211;418&#41; pg&#47;mL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the echocardiography indices indexed to BSA&#44; including IVC diameter in inspiration&#44; expiration and left atrial diameter&#46; The median IVC diameter on inspiration&#47;BSA was higher in group I &#40;3&#46;02 &#40;0&#46;58&#8211;10&#46;7&#41; mm&#47;m<span class="elsevierStyleSup">2</span>&#41; than in group III &#40;1&#46;66 &#40;0&#46;22&#8211;4&#46;34&#41; mm&#47;m<span class="elsevierStyleSup">2</span>&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;012&#41;&#46; No significant change in IVC diameter expiration&#47;BSA&#44; IVC index&#44; left atrial diameter&#47;BSA was found among the groups&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">BIA assessment was used as another indicator of volume status in the study cohort&#46; A comparison between the groups are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Over hydration&#44; Relative OH &#40;OH&#47;ECW &#37;&#41;&#44; TBW&#47;BSA&#44; ECW&#47;BSA&#44; ECW&#47;ICW&#44; ECW&#47;TBW were higher in group I as compared with the group II and III&#46; There was no significant difference in the ratio of ICW to BSA in the groups &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">No significant correlation was present between BIA parameters&#44; biochemical parameters&#44; NT-proBNP and echocardiographic measurements in group I and group II&#46; Serum NT-proBNP did not correlate with any other variables in group I and group II&#44; but it did correlate with TBW&#47;BSA &#40;<span class="elsevierStyleItalic">r</span>&#58; &#8722;0&#46;527 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#44; ECW&#47;BSA &#40;<span class="elsevierStyleItalic">r</span>&#58; &#8722;0&#46;579 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and ECW&#47;ICW &#40;<span class="elsevierStyleItalic">r</span>&#58; &#8722;0&#46;452 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41; in group III&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">In this study&#44; we observed that neither debut nor relapse nephrotic patients had symptoms of hypovolemia&#46; Also&#44; we found that plasma renin activities&#44; aldosterone levels were not different between groups indicating that edema did not develop as a result of activation of renin&#8211;angiotensin&#8211;aldosterone &#40;RAA&#41; with a hypovolemic contributing factor&#46; Moreover&#44; our study showed that VCI index&#44; left atrial diameter measured in children with debut or relapse NS were not significantly different than the controls whereas NT-proBNP values were higher than the remission and control groups&#46; Lastly&#44; by using BIA we demostrated that TBW values were increased in association with high ECW but without any change in ICW in patients with NS during attack&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Several methods including clinical signs and symptoms&#44; neurohumoral hormone assays&#44; blood volume measurement with radioactive labeling techniques and IVCD measurements have been utilized in NS patients to assess the hydration status&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6&#44;7&#44;22&#8211;33</span></a> Consistent to several recent studies&#44; during the debute or relapse period&#44; the symptoms of hypovolemia including tachycardia&#44; pallor or abdominal pain were not observed in our study&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">23&#44;25&#44;28</span></a> Plasma renin and aldosterone levels of patients with NS have been investigated widely in previous studies&#46; Elevated renin or aldosterone levels have only been confirmed in about half of studied nephrotic subjects<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10&#44;22&#44;27&#44;30&#44;31</span></a> while some other studies have noted normal or lower values&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">5&#44;23&#44;31</span></a> In our study&#44; the sodium reabsorption was significantly decreased in Group I patients compared to Group II and III&#46; Lower FENa&#43; values in Group I patients than other two groups&#44; despite the unsignificant difference in terms of plasma renin and aldosterone levels between groups may indicate the role of intrarenal mechanisms in sodium reabsorption in children with INS&#46; Besides renin and aldosterone&#44; we investigated the role of NT-proBNP in determining the volume status of children with NS&#46; NT-proBNP was high in the debut&#47;relapse group during disease&#46; Higher concentration of NT-proBNP in the debut&#47;relapse group suggests the overfill blood volume in these patients&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Previous studies investigating the central volume status by measurements of IVC and left atrial diameter by echocardiography yielded conflicting results in children with INS&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">23&#8211;25&#44;28&#44;34</span></a> Recently&#44; Gurgoze et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> reported left atrial diameter and IVCCI values were similar between patients with and without edema and concluded that patients with NS tended to be normovolemic instead of being hypovolemic&#46; Similarly our data show no significant difference between the groups in terms of IVC index and left atrial diameter but a tendency toward an increased IVC inspiratory diameter&#47;BSA ratio was seen in Group I compared with the group III&#46; Our data showed no significant correlation between IVC diameter and NT-proBNP and fluid volume by BIA&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The use of IVC as a marker of central blood volume filling should be researched in a larger patient group&#46; By the way&#44; this method can have some limitations&#46; That means for example&#44; the toddlers are less likely to lie still during the ultrasound tests&#46; It causes most probably undesired biases for measurements&#46; Since the toddlers cry&#44; intra-thoracic and intra-abdominal pressure will obviously increase&#46; Therefore it will show some critical deviances in the IVC diameter measurements&#46; These limitations may underlie the discordance between the current results and the previously reported of echocardiographic IVC measurements<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">24&#44;25&#44;28&#44;34</span></a>&#46; Point-of-care ultrasound of IVC was not reliable enough to be used as an independent screening method for volume overload to assess younger children&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Although fluid management is based primarily on subjective clinical assessment&#44; clinicians need noninvasive bedside tools to provide a more objective assessment of fluid status&#46; Multifrequency bioimpedance measurement has been claimed to be a reliable noninvasive technology for estimating body water compartments in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">16&#44;35</span></a> Its usage in pediatric patients&#8217; has also been advocated&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">23&#44;34&#44;36&#8211;40</span></a> The use of relative overhydration &#40;Rel OH&#41; allows for hydration status comparison between all patient groups including children&#46; Two pediatric abstracts showed the utility of BIA in children older than 2 years of age&#46; One of them validated and established fluid and body composition reference values in 430 healthy children&#59; the other one showed a very similar total body water content estimate by BIA and by the Morgenstern equation&#44; which is the only equation for TBW assessment validated in children on dialysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">38&#44;40</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">As in the latter study&#44; we observed increased TBW in patients with debut or relapse NS compared to healthy controls in association with increased ECW but without any change in ICW&#46; Previously&#44; Gurgoze et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> calculated TBW by measuring resistance and reactance values using a 50<span class="elsevierStyleHsp" style=""></span>kHz BIA device and TBW was found to be markedly higher in patients with edema&#46; Despite the methodological differences between the two studies&#44; patients with NS tended to be hypervolemic instead of being hypovolemic and the increase in TBW is likely associated with increased ECW without any change in ICW&#46; Although BIA was found to be reliable and practical method in pediatric patients on hemodialysis&#44; there is scarce data regarding the usefulness of BIA to evaluate volume status in children with nephrotic syndrome&#46; More recently&#44; &#214;zdemir et al&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">34</span></a> evaluated the clinical findings&#44; echocardiographic measurements &#40;IVC index and IVC collapsibility index&#41; and BIA to determine the volume status of 34 children with NS and controls&#46; The authours concluded that BIS may be a superior technique to echocardiography since the sensitivity and specificity of BIA is relatively higher&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Natriuretic peptides play a key role in regulation of blood pressure and volume homeostasis due to their natriuretic&#47;diuretic and vasodilatory actions&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">41</span></a> Several previous studies have shown the strong relationship between natriuretic peptides and left ventricular hypertrophy&#44; systolic dysfunction but most of the patients included in these studies were prevalent dialysis patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">42&#44;43</span></a> We preferred the use of NT-proBNP due to its in vitro stability appropriate for routine clinical use and longer half-life of BNP compared to ANP&#46; We found that NT-proBNP level in Group I was significantly higher compared to Group II and Group III&#46; NT-proBNP levels waned during remission&#44; supporting the volume expansion with NS&#46; In the study by Andersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">24</span></a> higher ANP and NT-proBNP levels were found in children with aldosterone-suppressed group compared to remission groups suggesting possible overfill blood volume&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">To date&#44; however there has been no study evaluating the relationship among NT-proBNP&#44; echocardiography measurements and BIA parameters in children with NS&#46; We did not find any correlation between the parameters of BIA &#40;OH&#44; Rel OH&#44; TBW&#47;BSA&#44; ECW&#47;BSA&#44; ECW&#47;ICW&#44; ECW&#47;TBW&#41; and NT-proBNP in Group I and Group II but positive correlations was observed between ECW&#47;BSA&#44; ECW&#47;ICW and ECW&#47;TBW and NT-proBNP in Group III&#46; These findings may be explained by the renal unresponsiveness to the natriuretic peptides which was previously proposed in NS patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">44&#44;45</span></a> Despite their increased levels in NS and other edematous conditions&#44; the underlying renal unresponsiveness to natriuretic peptides include&#59; decreased renal perfusion pressure&#44; RAAS&#44; increased levels of antagonist hormones such as endothelin and AVP&#44; down-regulation in natriuretic peptide receptors&#44; increased breakdown by endopeptidases and release of less active forms&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">45</span></a> The presence of correlation between BIA values and NT-proBNP only in the control group and not in the patients groups may indicate the alteration of the relationship between NT-proBNP and hydration status&#46; The present study has not been specifically designed to explain this observation&#59; however&#44; down-regulation of natriuretic peptide receptors or increased breakdown by neutral endopeptidases may play a role in renal unresponsiveness&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">One of this study&#39;s weakness is the fact that the subgroup of patients with NS and remission is very small and the lack of long-term&#44; longitudinal-serial measurements&#46; The other limitation was that the sodium intake could not be standardized in these patients studied just at debut or relapse&#46; This may contribute the substantial variation on urinary sodium excretion&#46; It is also important to note that our data represent a single center report&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results indicate that renin&#44; aldosterone&#44; VCI index&#44; left atrial diameter measured in children with debut or relapse NS were not significantly different than the controls whereas NT-proBNP values were higher than the remission and control groups&#46; Increased TBW values&#44; in association with high ECW but without any change in ICW&#44; indicates the lack of hypovolemia in children with NS&#46; Since BIA provides results immediately&#44; it might be an additional tool for everyday care of difficult patients with NS&#44; whereas natriuretic peptides results are not available in a fast manner most of the time&#46; Further studies are needed to evaluate the utility of BIA at the follow-up children with NS&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical approval</span><p id="par0180" class="elsevierStylePara elsevierViewall">This study was supported by Ondokuz Mayis University Department of Scientific Research Projects&#46; All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and&#47;or national research committee at which the studies were conducted &#40;PYO&#46; TIP&#46;1901&#46;12&#46;019&#41; and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors have declared that no conflict of interest exists&#46;</p></span></span>"
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              "titulo" => "Blood and urine samples"
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              "titulo" => "Bioimpedance measurement"
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              "titulo" => "Baseline demographic and clinical and biochemical characteristics of the study population"
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              "titulo" => "Comparison between volume status assessment methods"
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            1 => "NT-proBNP"
            2 => "Inferior vena cava diameter"
            3 => "Nephrotic syndrome"
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            0 => "BIA"
            1 => "NT-proBNP"
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            3 => "S&#237;ndrome nefr&#243;tico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Assessment of volume status and differentiating &#8220;underfill&#8221; and &#8220;overfill&#8221; edema is essential in the management of patients with nephrotic syndrome &#40;NS&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Our aim was to evaluate the volume status of NS patients by using different methods and to investigate the utility of bioelectrical impedance analysis &#40;BIA&#41; in children with NS&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The hydration status of 19 patients with NS &#40;before treatment of NS and at remission&#41; and 25 healthy controls was assessed by multifrequency BIA&#44; serum N-terminal-pro-brain natriuretic peptide &#40;NT-proBNP&#41; levels&#44; inferior vena cava &#40;IVC&#41; diameter&#44; left atrium diameter &#40;LAD&#41; and vasoactive hormones&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Renin&#44; aldosterone levels&#44; IVC diameter and LAD were not statistically different between the groups&#46; NT-proBNP values were statistically higher in the attack period compared to remission and the control group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005 for each&#41;&#46; Total body water &#40;TBW&#41;&#44; overhydration &#40;OH&#41; and extracellular water &#40;ECW&#41; estimated by the BIA measurement in the attack group was significantly higher than that of the remission group and controls&#46; There were no significant correlations among volume indicators in group I and group II&#46; However&#44; significant correlations were observed between NT-proBNP and TBW&#47;BSA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#44; ECW&#47;BSA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and ECW&#47;ICW &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41; in the healthy group&#46; TBW was found to be higher in patients with NS in association with increased ECW but without any change in ICW&#46; NT-proBNP values were higher in patients during acute attack than during remission&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Our findings support the lack of hypovolaemia in NS during acute attack&#46; In addition&#44; BIA is an easy-to-perform method for use in routine clinical practice to determine hydration status in patients with NS&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La evaluaci&#243;n del estado volum&#233;trico y la diferenciaci&#243;n entre edema &#171;por sobrellenado&#187; y &#171;por infrallenado&#187; es fundamental en el manejo de los pacientes con s&#237;ndrome nefr&#243;tico &#40;SN&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo fue evaluar el estado volum&#233;trico de los pacientes con SN mediante el uso de diversos m&#233;todos y estudiar la utilidad del an&#225;lisis de impedancia bioel&#233;ctrica &#40;BIA&#41; en ni&#241;os con SN&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se evalu&#243; el estado de hidrataci&#243;n de 19 pacientes con SN &#40;antes del tratamiento y en la remisi&#243;n&#41; y de 25 controles sanos mediante BIA multifrecuencia&#44; valores plasm&#225;ticos de la fracci&#243;n N-terminal del p&#233;ptido natriur&#233;tico cerebral &#40;NT-proBNP&#41;&#44; di&#225;metro de la vena cava inferior&#44; di&#225;metro de la aur&#237;cula izquierda y hormonas vasoactivas&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La renina&#44; los niveles de aldosterona&#44; el di&#225;metro de la vena cava inferior y el de la aur&#237;cula izquierda no fueron estad&#237;sticamente diferentes entre los grupos&#46; Los valores de la NT-proBNP fueron estad&#237;sticamente m&#225;s altos en el per&#237;odo de crisis que en el momento de remisi&#243;n y que en el grupo de control &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005 en cada uno&#41;&#46; El agua total corporal &#40;TBW&#41;&#44; la hiperhidrataci&#243;n y el agua extracelular &#40;ECW&#41; estimada mediante la medici&#243;n del BIA en el grupo de crisis fue considerablemente mayor que la del grupo de remisi&#243;n y los controles&#46; No hubo correlaciones importantes entre los indicadores de volumen en el grupo <span class="elsevierStyleSmallCaps">i</span> y en el grupo <span class="elsevierStyleSmallCaps">ii</span>&#46; Sin embargo&#44; se observaron correlaciones considerables entre NT-proBNP y TBW&#47;BSA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#44; ECW&#47;BSA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; y ECW&#47;ICW &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;023&#41; en el grupo sano&#46; Se encontr&#243; que TBW fue mayor en los pacientes con SN relacionado con el aumento de ECW&#44; pero sin ning&#250;n cambio en ICW&#46; Los valores de la NT-proBNP fueron m&#225;s altos en los pacientes durante la crisis aguda que durante la remisi&#243;n&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nuestros hallazgos apoyan la falta de hipovolemia en el SN durante la crisis aguda&#46; Adem&#225;s&#44; BIA es un m&#233;todo f&#225;cil de utilizar en la pr&#225;ctica cl&#237;nica habitual para determinar el estado de hidrataci&#243;n en pacientes con SN&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group I<br>&#40;debut&#47;relaps&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group II<br>&#40;remission&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group III<br>&#40;control&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><br>&#40;groups I&#8211;III&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><br>&#40;groups I&#8211;II&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BSA<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71 &#40;0&#46;49&#8211;1&#46;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;67 &#40;0&#46;49&#8211;1&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;76 &#40;0&#46;5&#8211;1&#46;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;582<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;404<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;3 &#40;15&#46;6&#8211;22&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;9 &#40;14&#46;5&#8211;21&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;7 &#40;13&#46;7&#8211;24&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;327<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systolic blood pressure&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;030<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;773<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diastolic blood pressure<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#40;45&#8211;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;40&#8211;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;46&#8211;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;033<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;380<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">P-albumin<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;73 &#40;1&#46;1&#8211;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;39 &#40;3&#46;4&#8211;4&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;5 &#40;4&#46;5&#8211;4&#46;99&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Proteinuria<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><br>&#40;spot urine&#44; mg&#47;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;5 &#40;2&#46;03&#8211;28&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13 &#40;0&#46;10&#8211;0&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;16 &#40;0&#46;09&#8211;0&#46;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fe<span class="elsevierStyleInf">Na&#43;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;&#37;&#41;<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1 &#40;0&#8211;0&#46;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;47 &#40;0&#46;08&#8211;1&#46;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;31 &#40;0&#46;05&#8211;11&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;002<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renin<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;ng&#47;mL&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;76 &#40;0&#46;03&#8211;23&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;32 &#40;0&#46;38&#8211;13&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;98 &#40;0&#46;34&#8211;19&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;671<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;594<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aldosterone<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;35 &#40;0&#46;96&#8211;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;27 &#40;1&#46;5&#8211;46&#46;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;6 &#40;0&#46;77&#8211;210&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;151<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;225<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
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              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Data shown as median values with range because of the non-normality of data according to the Shapiro&#8211;Wilk test&#46;</p>"
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              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">According to independent sample <span class="elsevierStyleItalic">t</span> test&#46;</p>"
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              "identificador" => "tblfn0020"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">According to Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46;</p>"
            ]
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              "identificador" => "tblfn0025"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">According to Wilcoxon rank-sum test&#46;</p>"
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              "etiqueta" => "f"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">According to paired <span class="elsevierStyleItalic">t</span>-tests&#46;</p> <p class="elsevierStyleNotepara" id="npar0035"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered significant&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Demographic&#44; clinical and biochemical data of the of the study population&#46;</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Data are presented as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviations &#40;x<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41; or as median with range&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group I<br>&#40;debut&#47;relapse&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group II<br>&#40;remission&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group III<br>&#40;control&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><br>&#40;groups I&#8211;III&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><br>&#40;group I&#8211;II&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IVC diameter inspiration&#47;BSA<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">b</span></a> &#40;mm&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;02 &#40;0&#46;58&#8211;10&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;92 &#40;0&#46;50&#8211;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;66 &#40;0&#46;22&#8211;4&#46;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;012<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;799<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IVC diameter expiration&#47;BSA &#40;mm&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;745<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;727<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IVC index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;095<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0060">According to paired <span class="elsevierStyleItalic">t</span>-tests&#46;</p> <p class="elsevierStyleNotepara" id="npar0065"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered significant <span class="elsevierStyleItalic">p</span> value of &#60;0&#46;05 &#40;controls vs&#46; patients&#41;&#46;</p> <p class="elsevierStyleNotepara" id="npar0070">OH&#58; Absolute fluid overload &#40;AFO&#41;&#46;</p> <p class="elsevierStyleNotepara" id="npar0075">Rel OH&#58; relative fluid overload &#40;RFO&#41; is defined as the AFO to ECW ratio&#46;</p> <p class="elsevierStyleNotepara" id="npar0080">ECW&#58; extracellular water&#46;</p> <p class="elsevierStyleNotepara" id="npar0085">ICW&#58; intracellular water&#46;</p> <p class="elsevierStyleNotepara" id="npar0090">TBW&#58; total body water&#46;</p> <p class="elsevierStyleNotepara" id="npar0095">E&#47;I&#58; ECW&#47;ICW&#46;</p>"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Assessment of ECW And Fluid Status in Study Population&#46;</p>"
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                      "titulo" => "Understanding the nephrotic syndrome&#58; what&#39;s new in a decade&#63;"
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        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0190" class="elsevierStylePara elsevierViewall">We thank those of our patients and clinical colleagues who have supported this research&#46;</p> <p id="par0195" class="elsevierStylePara elsevierViewall">We presented this study as a poster presentation in the 47th ESPN Congress in Porto&#44; Portugal&#44; September 18&#8211;20&#44; 2014 &#40;p206&#41;&#46; This study was supported by <span class="elsevierStyleGrantSponsor" id="gs3">Ondokuz Mayis University</span> Department of Scientific Research Projects&#46;</p>"
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Original article
The role of bioelectrical impedance analysis, NT-ProBNP and inferior vena cava sonography in the assessment of body fluid volume in children with nephrotic syndrome
El papel del análisis de impedancia bioeléctrica, la NT-proBNP y la ecografía de vena cava inferior en la evaluación del volumen de líquidos corporales en niños con síndrome nefrótico
Hulya Nalcacioglua,
Autor para correspondencia
hulyanalcacoglu@hotmail.com

Corresponding author.
, Ozan Ozkayaa, Kemal Baysalb, Hassan Candas Kafalib, Bahattin Avcic, Demet Tekcana, Gurkan Genca
a Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
b Pediatric Cardiology Department, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
c Medical Biochemistry Department, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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cannot explain all features of volume regulation and sodium reabsorption in the nephrotic syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">3&#8211;5</span></a> Children with edema associated with idiopathic NS &#40;INS&#41; do not commonly have intravascular volume depletion&#59; actually several studies suggest that children with INS may have normal or even increased intravascular pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6&#44;7</span></a> The overfill hypothesis now suggests that edema is a result of a primary renal defect in sodium excretion that is independent of low oncotic pressure and is responsible for primary extracellular volume expansion&#44; which leads to secondary leakage of fluid toward the interstitium&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">While the mechanism of edema is a theoretical topic of discussion&#44; understanding the intravascular volume status of the patients accurately is a crucial issue while planning the treatment of edema&#46; However&#44; a significant issue in the consideration of this problem is the lack of a gold standard for the assessment of intravascular volume&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">10</span></a> Several noninvasive techniques for the assessment of hydration status exist&#46; Monitoring of relative blood volume changes&#44; inferior vena cava diameter &#40;IVCD&#41; measurements and biochemical markers such as atrial atriuretic peptide &#40;ANP&#41;&#44; brain natriuretic peptide &#40;BNP&#41; are indirect methods&#44; which provide information about the intravascular filling&#46; Although dilution methods are accepted as the most appropriate standards for fluid volume determination&#44; they cannot be applied in routine clinical practice due to the patient availability for many hours and time-consuming assays of blood samples&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10&#8211;12</span></a> In recent years&#44; Bioelectrical impedance analysis &#40;BIA&#41; has found a place in the literature as a practical method for measuring body fluids particularly for patients on hemodialysis due to its advantages such as ease of application&#44; non-invasiveness&#44; and reproducibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">12&#8211;17</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The present study aimed to determine the volume status using multifrequency BIA&#44; NT-proBNP levels&#44; IVC&#44; LAD measurements to examine the relationship between various volume indicators and to investigate the utility of BIA in evaluating the volume status in children with INS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Nineteen children &#40;11 males&#44; 8 females&#41; with NS at debut or relapse admitted to our nephrology unit were prospectively studied from September 2012 to October 2013&#46; The age range was 1&#8211;11 years &#40;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#44; 5&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;53 years&#41;&#46; Nephrotic syndrome was defined as severe proteinuria over 40<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#47;h&#44; hypoalbuminemia &#40;&#60;2&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; and edema&#46; Relapse was defined as three consecutive days with plus two or more on urinary albumin dipstick&#46; Remission was achieved when urinary dipstick was negative for protein for three consecutive days&#46; Patients were classified as steroid resistant when remission was not achieved with prednisone therapy at 60<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day for 4 weeks&#46; All patients were treated with prednisone&#44; per International Study of Kidney Disease in Children regimen<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">18</span></a> &#40;started after routine workup for new NS patients and immediately upon admission in relapsed NS patients&#41;&#46; Patients were excluded from the study if they met any of the following criteria&#58; established cardiovascular disease&#44; evidence of secondary NS and specific glomerulonephritis&#44; usage of steroids or immunosuppressive drugs during the previous six months&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Twenty-five age and sex matched healthy volunteers served as the control group&#46; These subjects had normal blood pressure &#40;BP&#41;&#44; no clinical electrocardiographic &#40;ECG&#41; or echocardiographic evidence of cardiovascular disease&#44; and no evidence of pulmonary disease&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study design</span><p id="par0030" class="elsevierStylePara elsevierViewall">A complete review was carried out for each patient which included the patient&#39;s past and family history&#44; physical examination and data such as gender&#44; age&#44; height&#44; weight&#44; blood pressure &#40;BP&#41; on admission&#46; Their clinical edema findings were appraised by the same pediatric nephrologist&#46; Hypertension was defined as blood pressure of more than the 95th percentile for gender&#44; age and height&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">19</span></a> Tachycardia was defined as a heart rate above the upper heart rate limit adjusted for age&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Biochemistry analyses&#44; serum NT-proBNP&#44; anthropometric and BP measurements&#44; BIA&#44; and IVC&#44; left atrial diameter by echocardiography were performed at baseline in all participants&#46; Blood and urine samples were collected for the laboratory assessments listed in the study protocol&#46; Then&#44; the serum samples were stored at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C for NT-proBNP measurements&#46; Prednisolone treatment was initiated after the first evaluation of the patients&#46; Physical examination&#44; laboratory assessments&#44; BIA&#44; echocardiographic evaluation and NT- proBNP measurements were repeated during the remission period in the patients group&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Control data were used to compare the results of laboratory assessments&#44; BIA&#44; cardiovascular &#40;IVC and left atrial diameter&#41; and NT-proBNP measurements&#46; This study was approved by the ethics committee of the Medical Faculty of Ondokuz Mayis University&#46; Informed assent and consent were obtained from their parents before the study began&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">According to the study group&#44; the patients were evaluated into two categories&#58; Debut or relapse of NS in admission &#40;group I&#41; and in remission after treatment &#40;group II&#41;&#46; Healthy volunteers served as the control group &#40;group III&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Blood and urine samples</span><p id="par0050" class="elsevierStylePara elsevierViewall">Blood and urine samples were collected at debut or relapse of NS and when stable remission &#40;10&#8211;14 days after initiation of treatment&#41; was achieved&#46; The medication &#40;steroids&#41; was continued in unchanged dosages during the 10&#8211;14 days of study&#46; Blood samples for measurements of serum creatinine&#44; albumin&#44; sodium and urine analysis of creatinine&#44; sodium&#44; protein excretion from spot urine samples were analyzed at the Department of Clinical Biochemistry using standard procedures&#46; Fractional excretion of sodium &#40;FENa&#44; &#37;&#41; was calculated by on spot urine tests by the formula&#59; serum aldosterone levels and plasma renin activity were determined by using Beckman Coulter RIA &#40;Radioimmunoassay&#41; kits with a Gamma counter device &#40;ISO Data Multiwell Gamma Counter&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">For determination of NT-proBNP&#44; venous blood samples were collected in biochemistry tubes without anticoagulant and allowed to coagulate&#46; The samples were centrifuged &#40;4000<span class="elsevierStyleHsp" style=""></span>rpm for 5<span class="elsevierStyleHsp" style=""></span>min at &#43;4<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; and the serum frozen at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C until analysis&#46; The kits and serum samples were allowed to reach room temperature &#40;&#43;25<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; before the measurement&#46; Serum NT-proBNP levels were measured by ELFA &#40;enzyme-linked fluorescent assay&#41; method using a VIDAS PC device &#40;bioMERIEUX&#44; France&#41; with commercial NT-proBNP kits &#40;VIDAS&#38;NT-proBNP&#44; bioMERIEUX&#44; France&#41; at the Investigational Laboratory of Ondokuz Mayis University School of Medicine&#46; The results were expressed as pg&#47;mL&#46; The analytical measurement reference range of the NT-proBNP kit was 20&#8211;25&#44;000<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#46; The measurement was performed as per the procedure of the manufacturer&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Bioimpedance measurement</span><p id="par0060" class="elsevierStylePara elsevierViewall">Two bioimpedance analysis &#40;BIA&#41; are currently available for use in clinical practice&#58; single-frequency bioimpedance analysis and multifrequency bioimpedance spectroscopy &#40;BIS&#41;&#46; Single-frequency BIA&#44; measures whole body impedance using one electrical current with a frequency of 50<span class="elsevierStyleHsp" style=""></span>kHz&#46; Therefore this cannot differentiate between extracellular and total body fluid resistances because this frequency of electrical currents do not pass cell membranes&#46; The multifrequency bioimpedance spectroscopy &#40;BIS&#41; depends on a different electrical model&#46; ECW and TBW resistances are determined using multiple imperceptible currents of varying frequencies and these water volumes are calculated from the respective impedances&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">20</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We applied the Body Composition Monitor &#40;BCM&#44; Fresenius Medical Care&#41; using multi-frequency BIS in order to assess the hydration status&#46; Four electrodes were placed on each side on the dorsal surfaces of hands and feet of the supine patients&#46; Two electrodes were dorsally placed in the metacarpophalangeal articulations and in the carpus of the hand respectively&#46; The pair on the foot was located in the metatarsophalangeal and in the ankle articulation&#46; Patients were connected to the device with these electrodes and measurements completed in 1&#8211;4<span class="elsevierStyleHsp" style=""></span>min after entering gender&#44; height &#40;in cm&#41;&#44; body weight &#40;in kilograms&#41;&#44; and blood pressure &#40;systolic and diastolic mm Hg&#41; data for each patient&#46; Body composition analysis was performed by using Fluid Management Tool version 3&#46;2&#46;11 software&#46; In cases with inadequate data quality&#44; the measurements were repeated by changing the electrodes&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Results of measurements included that of overhydration &#40;OH&#41;&#44; total body water &#40;TBW&#41;&#44; extracellular water &#40;ECW&#41;&#44; intracellular water &#40;ICW&#41;&#44; body mass index &#40;BMI&#41;&#46; Bioimpedance spectroscopy &#40;BIS&#41; uses physiological modeling and mixture equations &#40;Cole&#8211;Cole plot and Hanai formulae&#41; to first determine the electrical resistance of ECW and ICW and then calculate the volumes of these respective compartments&#46; This is essential for identification of OH&#46; The BCM uses the BIS technique&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">20</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The BCM states the body weight in means of lean tissue mass &#40;LTM &#8211; mainly muscle&#41;&#44; adipose tissue mass &#40;ATM &#8211; mainly fat&#41; and overhydration &#40;OH&#41;&#46; OH is almost 100&#37; ECW&#44; whereas the water of LTM and ATM consist differing ratio of ECW and ICW in addition to solid components&#46; As the extracellular hydration of LTM and ATM is known&#44; the estimated &#8220;normal&#8221; volume of ECW of these tissues can be calculated&#46; The difference between &#8220;normal&#8221; ECW and measured ECW is the excess fluid&#44; OH&#46; Reference ranges are available for OH&#44; lean tissue index &#40;LTI&#41;&#44; fat tissue index &#40;FTI&#41; and extracellular&#47;intracellular &#40;E&#47;I&#41; ratio&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a> These ranges simplify identification of abnormal conditions by evaluating the patient&#39;s results to the reference population&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Echocardiographic measurements</span><p id="par0080" class="elsevierStylePara elsevierViewall">Echocardiographic evaluations were performed at the time of BIA investigation by the same pediatric cardiologist&#44; using the &#8220;Toshibo Aplio 770s Echocardiography System&#8221; with 3&#46;5 and 5&#46;5<span class="elsevierStyleHsp" style=""></span>MHz probes as appropriate for age after resting &#40;for 10&#8211;30<span class="elsevierStyleHsp" style=""></span>minutes&#41; in the supine position&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All examinations were measured IVCD was measured from subxiphoidal long axis position in 2<span class="elsevierStyleHsp" style=""></span>cm to its junction to right atrium before the p wave in the electrocardiogram&#46; The maximum diameter in expiration and the minimum diameter in deep inspiration were measured and indexed for body surface area &#40;BSA&#41;&#46; Left atrium diameter &#40;LAD&#41; was measured at the parasternal position&#46; LAD was determined as diameter of left atrium &#40;mm&#41;&#47;body surface area &#40;m<span class="elsevierStyleSup">2</span>&#41;&#46; The patients were scanned during debut or relaps NS and at remission periods&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical evaluation</span><p id="par0090" class="elsevierStylePara elsevierViewall">Statistical analyses were performed using &#8220;SPSS for Windows<span class="elsevierStyleSup">&#169;</span> 15&#46;0&#8221; &#40;Statistical Program in Social Sciences&#41; package software&#46; Data are presented as mean and standard deviation &#40;SD&#41; or as median and ranges &#40;minimum&#8211;maximum&#41; according to their distribution&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">For the comparisons between the patient group and the control group&#44; the independent samples <span class="elsevierStyleItalic">t</span>-test was used for the parameters with normal distribution and the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test was used for the parameters with non-normal distribution&#46; The pre- and post-treatment data of the patient group were compared using the paired samples <span class="elsevierStyleItalic">t</span>-test or the Wilcoxon rank-sum test&#46; To determine the significance and strength of associations&#44; we used the Pearson&#39;s correlation coefficient <span class="elsevierStyleItalic">r</span> for analyses of associations between continuous variables and Spearman rank for non-parametric variables&#46; The <span class="elsevierStyleItalic">p</span> values below 0&#46;05 were considered as statistically significant&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Baseline demographic and clinical and biochemical characteristics of the study population</span><p id="par0100" class="elsevierStylePara elsevierViewall">A total of 19 patients with debut &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#41; or relapse &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41; of NS and 25 healthy children were enrolled in the study&#46; Demographic and clinical data of the study groups are reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; In the present study&#44; 17 patients were diagnosed with INS based on the clinical and laboratory findings&#44; and steroid therapy was initiated without obtaining kidney biopsy&#46; The diagnosis of MCNS was supported after biopsy in one patient who remained refractory to steroid therapy&#46; Two patients older than 10 years were biopsied and then steroid treatment was started with the diagnosis of MCNS&#46; 3 patients were excluded from group II because of refractory to steroid therapy&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The mean &#40;&#177;SD&#41; age of the patient and control populations were similar &#40;5&#46; 1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;53 vs&#46; 5&#46;98<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;84 years&#44; respectively&#41; and according to gender distribution&#44; there were 8 girls and 11 boys in NS group and 16 girls and 9 boys in control group&#46; There were no significant differences in age&#44; gender&#44; weight&#44; height or BSA between the patient and control groups&#46; The median BMI was significantly higher in group I than in group III &#91;18&#46;3 &#40;15&#46;6&#8211;22&#46;7&#41; vs&#46; 16&#46;7 &#40;13&#46;7&#8211;24&#46;2&#41; kg&#47;m<span class="elsevierStyleSup">2</span>&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#93;&#46; There was no difference in the BMI values between group I and group II &#40;data was shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The remaining comparison of the patients with NS and control group are given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; None of the patients had clinical signs of hypovolemia&#44; such as tachycardia&#44; pallor or abdominal pain&#46; Eight &#40;42&#46;1&#37;&#41; were hypertensive at the time of investigation&#46; Compared with healthy controls&#44; group I had significantly higher systolic and diastolic blood pressure but not significant in the group I and the group II &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; In addition to the significantly higher proteinuria and lower serum albumin concentrations&#44; patients had lower FE<span class="elsevierStyleInf">Na</span> levels&#44; the lowest in the group I&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the laboratory measurements&#44; including serum albumin&#44; spot urine&#47;creatinine&#44; FE<span class="elsevierStyleInf">Na</span> serum renin and aldosterone levels in patients and controls&#46; All the laboratory measurements were statistically significant different in group I than in group III&#59; however&#44; there was no difference in serum renin and aldosterone levels among the groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Comparison between volume status assessment methods</span><p id="par0110" class="elsevierStylePara elsevierViewall">Patients&#8217; and healthy controls volume status were investigated at the same time using echocardiographically derived parameters &#40;IVC&#41;&#44; cardiac biomarkers &#40;NT-proBNP&#41; and BIA parameters&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Group I patients&#8217; had significantly higher NT-proBNP value in comparison to the group II &#40;114 &#40;20&#8211;1031&#41; vs&#46; 30 &#40;20&#8211;514&#41; pg&#47;mL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; and group III &#40;114 &#40;20&#8211;1031&#41; vs&#46; 29 &#40;20&#8211;418&#41; pg&#47;mL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the echocardiography indices indexed to BSA&#44; including IVC diameter in inspiration&#44; expiration and left atrial diameter&#46; The median IVC diameter on inspiration&#47;BSA was higher in group I &#40;3&#46;02 &#40;0&#46;58&#8211;10&#46;7&#41; mm&#47;m<span class="elsevierStyleSup">2</span>&#41; than in group III &#40;1&#46;66 &#40;0&#46;22&#8211;4&#46;34&#41; mm&#47;m<span class="elsevierStyleSup">2</span>&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;012&#41;&#46; No significant change in IVC diameter expiration&#47;BSA&#44; IVC index&#44; left atrial diameter&#47;BSA was found among the groups&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">BIA assessment was used as another indicator of volume status in the study cohort&#46; A comparison between the groups are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Over hydration&#44; Relative OH &#40;OH&#47;ECW &#37;&#41;&#44; TBW&#47;BSA&#44; ECW&#47;BSA&#44; ECW&#47;ICW&#44; ECW&#47;TBW were higher in group I as compared with the group II and III&#46; There was no significant difference in the ratio of ICW to BSA in the groups &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">No significant correlation was present between BIA parameters&#44; biochemical parameters&#44; NT-proBNP and echocardiographic measurements in group I and group II&#46; Serum NT-proBNP did not correlate with any other variables in group I and group II&#44; but it did correlate with TBW&#47;BSA &#40;<span class="elsevierStyleItalic">r</span>&#58; &#8722;0&#46;527 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#44; ECW&#47;BSA &#40;<span class="elsevierStyleItalic">r</span>&#58; &#8722;0&#46;579 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and ECW&#47;ICW &#40;<span class="elsevierStyleItalic">r</span>&#58; &#8722;0&#46;452 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41; in group III&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">In this study&#44; we observed that neither debut nor relapse nephrotic patients had symptoms of hypovolemia&#46; Also&#44; we found that plasma renin activities&#44; aldosterone levels were not different between groups indicating that edema did not develop as a result of activation of renin&#8211;angiotensin&#8211;aldosterone &#40;RAA&#41; with a hypovolemic contributing factor&#46; Moreover&#44; our study showed that VCI index&#44; left atrial diameter measured in children with debut or relapse NS were not significantly different than the controls whereas NT-proBNP values were higher than the remission and control groups&#46; Lastly&#44; by using BIA we demostrated that TBW values were increased in association with high ECW but without any change in ICW in patients with NS during attack&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Several methods including clinical signs and symptoms&#44; neurohumoral hormone assays&#44; blood volume measurement with radioactive labeling techniques and IVCD measurements have been utilized in NS patients to assess the hydration status&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6&#44;7&#44;22&#8211;33</span></a> Consistent to several recent studies&#44; during the debute or relapse period&#44; the symptoms of hypovolemia including tachycardia&#44; pallor or abdominal pain were not observed in our study&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">23&#44;25&#44;28</span></a> Plasma renin and aldosterone levels of patients with NS have been investigated widely in previous studies&#46; Elevated renin or aldosterone levels have only been confirmed in about half of studied nephrotic subjects<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10&#44;22&#44;27&#44;30&#44;31</span></a> while some other studies have noted normal or lower values&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">5&#44;23&#44;31</span></a> In our study&#44; the sodium reabsorption was significantly decreased in Group I patients compared to Group II and III&#46; Lower FENa&#43; values in Group I patients than other two groups&#44; despite the unsignificant difference in terms of plasma renin and aldosterone levels between groups may indicate the role of intrarenal mechanisms in sodium reabsorption in children with INS&#46; Besides renin and aldosterone&#44; we investigated the role of NT-proBNP in determining the volume status of children with NS&#46; NT-proBNP was high in the debut&#47;relapse group during disease&#46; Higher concentration of NT-proBNP in the debut&#47;relapse group suggests the overfill blood volume in these patients&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Previous studies investigating the central volume status by measurements of IVC and left atrial diameter by echocardiography yielded conflicting results in children with INS&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">23&#8211;25&#44;28&#44;34</span></a> Recently&#44; Gurgoze et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> reported left atrial diameter and IVCCI values were similar between patients with and without edema and concluded that patients with NS tended to be normovolemic instead of being hypovolemic&#46; Similarly our data show no significant difference between the groups in terms of IVC index and left atrial diameter but a tendency toward an increased IVC inspiratory diameter&#47;BSA ratio was seen in Group I compared with the group III&#46; Our data showed no significant correlation between IVC diameter and NT-proBNP and fluid volume by BIA&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The use of IVC as a marker of central blood volume filling should be researched in a larger patient group&#46; By the way&#44; this method can have some limitations&#46; That means for example&#44; the toddlers are less likely to lie still during the ultrasound tests&#46; It causes most probably undesired biases for measurements&#46; Since the toddlers cry&#44; intra-thoracic and intra-abdominal pressure will obviously increase&#46; Therefore it will show some critical deviances in the IVC diameter measurements&#46; These limitations may underlie the discordance between the current results and the previously reported of echocardiographic IVC measurements<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">24&#44;25&#44;28&#44;34</span></a>&#46; Point-of-care ultrasound of IVC was not reliable enough to be used as an independent screening method for volume overload to assess younger children&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Although fluid management is based primarily on subjective clinical assessment&#44; clinicians need noninvasive bedside tools to provide a more objective assessment of fluid status&#46; Multifrequency bioimpedance measurement has been claimed to be a reliable noninvasive technology for estimating body water compartments in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">16&#44;35</span></a> Its usage in pediatric patients&#8217; has also been advocated&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">23&#44;34&#44;36&#8211;40</span></a> The use of relative overhydration &#40;Rel OH&#41; allows for hydration status comparison between all patient groups including children&#46; Two pediatric abstracts showed the utility of BIA in children older than 2 years of age&#46; One of them validated and established fluid and body composition reference values in 430 healthy children&#59; the other one showed a very similar total body water content estimate by BIA and by the Morgenstern equation&#44; which is the only equation for TBW assessment validated in children on dialysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">38&#44;40</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">As in the latter study&#44; we observed increased TBW in patients with debut or relapse NS compared to healthy controls in association with increased ECW but without any change in ICW&#46; Previously&#44; Gurgoze et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> calculated TBW by measuring resistance and reactance values using a 50<span class="elsevierStyleHsp" style=""></span>kHz BIA device and TBW was found to be markedly higher in patients with edema&#46; Despite the methodological differences between the two studies&#44; patients with NS tended to be hypervolemic instead of being hypovolemic and the increase in TBW is likely associated with increased ECW without any change in ICW&#46; Although BIA was found to be reliable and practical method in pediatric patients on hemodialysis&#44; there is scarce data regarding the usefulness of BIA to evaluate volume status in children with nephrotic syndrome&#46; More recently&#44; &#214;zdemir et al&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">34</span></a> evaluated the clinical findings&#44; echocardiographic measurements &#40;IVC index and IVC collapsibility index&#41; and BIA to determine the volume status of 34 children with NS and controls&#46; The authours concluded that BIS may be a superior technique to echocardiography since the sensitivity and specificity of BIA is relatively higher&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Natriuretic peptides play a key role in regulation of blood pressure and volume homeostasis due to their natriuretic&#47;diuretic and vasodilatory actions&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">41</span></a> Several previous studies have shown the strong relationship between natriuretic peptides and left ventricular hypertrophy&#44; systolic dysfunction but most of the patients included in these studies were prevalent dialysis patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">42&#44;43</span></a> We preferred the use of NT-proBNP due to its in vitro stability appropriate for routine clinical use and longer half-life of BNP compared to ANP&#46; We found that NT-proBNP level in Group I was significantly higher compared to Group II and Group III&#46; NT-proBNP levels waned during remission&#44; supporting the volume expansion with NS&#46; In the study by Andersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">24</span></a> higher ANP and NT-proBNP levels were found in children with aldosterone-suppressed group compared to remission groups suggesting possible overfill blood volume&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">To date&#44; however there has been no study evaluating the relationship among NT-proBNP&#44; echocardiography measurements and BIA parameters in children with NS&#46; We did not find any correlation between the parameters of BIA &#40;OH&#44; Rel OH&#44; TBW&#47;BSA&#44; ECW&#47;BSA&#44; ECW&#47;ICW&#44; ECW&#47;TBW&#41; and NT-proBNP in Group I and Group II but positive correlations was observed between ECW&#47;BSA&#44; ECW&#47;ICW and ECW&#47;TBW and NT-proBNP in Group III&#46; These findings may be explained by the renal unresponsiveness to the natriuretic peptides which was previously proposed in NS patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">44&#44;45</span></a> Despite their increased levels in NS and other edematous conditions&#44; the underlying renal unresponsiveness to natriuretic peptides include&#59; decreased renal perfusion pressure&#44; RAAS&#44; increased levels of antagonist hormones such as endothelin and AVP&#44; down-regulation in natriuretic peptide receptors&#44; increased breakdown by endopeptidases and release of less active forms&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">45</span></a> The presence of correlation between BIA values and NT-proBNP only in the control group and not in the patients groups may indicate the alteration of the relationship between NT-proBNP and hydration status&#46; The present study has not been specifically designed to explain this observation&#59; however&#44; down-regulation of natriuretic peptide receptors or increased breakdown by neutral endopeptidases may play a role in renal unresponsiveness&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">One of this study&#39;s weakness is the fact that the subgroup of patients with NS and remission is very small and the lack of long-term&#44; longitudinal-serial measurements&#46; The other limitation was that the sodium intake could not be standardized in these patients studied just at debut or relapse&#46; This may contribute the substantial variation on urinary sodium excretion&#46; It is also important to note that our data represent a single center report&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results indicate that renin&#44; aldosterone&#44; VCI index&#44; left atrial diameter measured in children with debut or relapse NS were not significantly different than the controls whereas NT-proBNP values were higher than the remission and control groups&#46; Increased TBW values&#44; in association with high ECW but without any change in ICW&#44; indicates the lack of hypovolemia in children with NS&#46; Since BIA provides results immediately&#44; it might be an additional tool for everyday care of difficult patients with NS&#44; whereas natriuretic peptides results are not available in a fast manner most of the time&#46; Further studies are needed to evaluate the utility of BIA at the follow-up children with NS&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical approval</span><p id="par0180" class="elsevierStylePara elsevierViewall">This study was supported by Ondokuz Mayis University Department of Scientific Research Projects&#46; All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and&#47;or national research committee at which the studies were conducted &#40;PYO&#46; TIP&#46;1901&#46;12&#46;019&#41; and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors have declared that no conflict of interest exists&#46;</p></span></span>"
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          "titulo" => "Materials and methods"
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              "titulo" => "Blood and urine samples"
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              "titulo" => "Bioimpedance measurement"
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              "titulo" => "Baseline demographic and clinical and biochemical characteristics of the study population"
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              "titulo" => "Comparison between volume status assessment methods"
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    "fechaRecibido" => "2016-10-10"
    "fechaAceptado" => "2017-04-02"
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            1 => "NT-proBNP"
            2 => "Inferior vena cava diameter"
            3 => "Nephrotic syndrome"
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            0 => "BIA"
            1 => "NT-proBNP"
            2 => "Di&#225;metro de la vena cava inferior"
            3 => "S&#237;ndrome nefr&#243;tico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Assessment of volume status and differentiating &#8220;underfill&#8221; and &#8220;overfill&#8221; edema is essential in the management of patients with nephrotic syndrome &#40;NS&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Our aim was to evaluate the volume status of NS patients by using different methods and to investigate the utility of bioelectrical impedance analysis &#40;BIA&#41; in children with NS&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The hydration status of 19 patients with NS &#40;before treatment of NS and at remission&#41; and 25 healthy controls was assessed by multifrequency BIA&#44; serum N-terminal-pro-brain natriuretic peptide &#40;NT-proBNP&#41; levels&#44; inferior vena cava &#40;IVC&#41; diameter&#44; left atrium diameter &#40;LAD&#41; and vasoactive hormones&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Renin&#44; aldosterone levels&#44; IVC diameter and LAD were not statistically different between the groups&#46; NT-proBNP values were statistically higher in the attack period compared to remission and the control group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005 for each&#41;&#46; Total body water &#40;TBW&#41;&#44; overhydration &#40;OH&#41; and extracellular water &#40;ECW&#41; estimated by the BIA measurement in the attack group was significantly higher than that of the remission group and controls&#46; There were no significant correlations among volume indicators in group I and group II&#46; However&#44; significant correlations were observed between NT-proBNP and TBW&#47;BSA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#44; ECW&#47;BSA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and ECW&#47;ICW &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41; in the healthy group&#46; TBW was found to be higher in patients with NS in association with increased ECW but without any change in ICW&#46; NT-proBNP values were higher in patients during acute attack than during remission&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Our findings support the lack of hypovolaemia in NS during acute attack&#46; In addition&#44; BIA is an easy-to-perform method for use in routine clinical practice to determine hydration status in patients with NS&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La evaluaci&#243;n del estado volum&#233;trico y la diferenciaci&#243;n entre edema &#171;por sobrellenado&#187; y &#171;por infrallenado&#187; es fundamental en el manejo de los pacientes con s&#237;ndrome nefr&#243;tico &#40;SN&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo fue evaluar el estado volum&#233;trico de los pacientes con SN mediante el uso de diversos m&#233;todos y estudiar la utilidad del an&#225;lisis de impedancia bioel&#233;ctrica &#40;BIA&#41; en ni&#241;os con SN&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se evalu&#243; el estado de hidrataci&#243;n de 19 pacientes con SN &#40;antes del tratamiento y en la remisi&#243;n&#41; y de 25 controles sanos mediante BIA multifrecuencia&#44; valores plasm&#225;ticos de la fracci&#243;n N-terminal del p&#233;ptido natriur&#233;tico cerebral &#40;NT-proBNP&#41;&#44; di&#225;metro de la vena cava inferior&#44; di&#225;metro de la aur&#237;cula izquierda y hormonas vasoactivas&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La renina&#44; los niveles de aldosterona&#44; el di&#225;metro de la vena cava inferior y el de la aur&#237;cula izquierda no fueron estad&#237;sticamente diferentes entre los grupos&#46; Los valores de la NT-proBNP fueron estad&#237;sticamente m&#225;s altos en el per&#237;odo de crisis que en el momento de remisi&#243;n y que en el grupo de control &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005 en cada uno&#41;&#46; El agua total corporal &#40;TBW&#41;&#44; la hiperhidrataci&#243;n y el agua extracelular &#40;ECW&#41; estimada mediante la medici&#243;n del BIA en el grupo de crisis fue considerablemente mayor que la del grupo de remisi&#243;n y los controles&#46; No hubo correlaciones importantes entre los indicadores de volumen en el grupo <span class="elsevierStyleSmallCaps">i</span> y en el grupo <span class="elsevierStyleSmallCaps">ii</span>&#46; Sin embargo&#44; se observaron correlaciones considerables entre NT-proBNP y TBW&#47;BSA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#44; ECW&#47;BSA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; y ECW&#47;ICW &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;023&#41; en el grupo sano&#46; Se encontr&#243; que TBW fue mayor en los pacientes con SN relacionado con el aumento de ECW&#44; pero sin ning&#250;n cambio en ICW&#46; Los valores de la NT-proBNP fueron m&#225;s altos en los pacientes durante la crisis aguda que durante la remisi&#243;n&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nuestros hallazgos apoyan la falta de hipovolemia en el SN durante la crisis aguda&#46; Adem&#225;s&#44; BIA es un m&#233;todo f&#225;cil de utilizar en la pr&#225;ctica cl&#237;nica habitual para determinar el estado de hidrataci&#243;n en pacientes con SN&#46;</p></span>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The ratio of ICW to BSA compared with group I&#44; II&#44; II&#46; <span class="elsevierStyleSup">&#42;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;586&#44; group I compared with group II&#59; <span class="elsevierStyleSup">&#42;&#42;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;893&#44; group I compared with group III&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">5&#46;98<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;387<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boys&#47;girls<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">11&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">9&#47;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;149&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group I<br>&#40;debut&#47;relaps&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group II<br>&#40;remission&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group III<br>&#40;control&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><br>&#40;groups I&#8211;III&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><br>&#40;groups I&#8211;II&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BSA<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71 &#40;0&#46;49&#8211;1&#46;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;67 &#40;0&#46;49&#8211;1&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;76 &#40;0&#46;5&#8211;1&#46;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;582<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;404<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;3 &#40;15&#46;6&#8211;22&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;9 &#40;14&#46;5&#8211;21&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;7 &#40;13&#46;7&#8211;24&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;327<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systolic blood pressure&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;030<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;773<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diastolic blood pressure<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#40;45&#8211;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;40&#8211;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;46&#8211;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;033<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;380<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">P-albumin<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;73 &#40;1&#46;1&#8211;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;39 &#40;3&#46;4&#8211;4&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;5 &#40;4&#46;5&#8211;4&#46;99&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Proteinuria<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><br>&#40;spot urine&#44; mg&#47;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;5 &#40;2&#46;03&#8211;28&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13 &#40;0&#46;10&#8211;0&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;16 &#40;0&#46;09&#8211;0&#46;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fe<span class="elsevierStyleInf">Na&#43;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;&#37;&#41;<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1 &#40;0&#8211;0&#46;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;47 &#40;0&#46;08&#8211;1&#46;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;31 &#40;0&#46;05&#8211;11&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;002<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renin<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;ng&#47;mL&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;76 &#40;0&#46;03&#8211;23&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;32 &#40;0&#46;38&#8211;13&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;98 &#40;0&#46;34&#8211;19&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;671<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;594<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aldosterone<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;35 &#40;0&#46;96&#8211;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;27 &#40;1&#46;5&#8211;46&#46;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;6 &#40;0&#46;77&#8211;210&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;151<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;225<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Categorical data compared using Chi-squared test</p>"
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            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Data shown as median values with range because of the non-normality of data according to the Shapiro&#8211;Wilk test&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">According to independent sample <span class="elsevierStyleItalic">t</span> test&#46;</p>"
            ]
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              "identificador" => "tblfn0020"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">According to Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46;</p>"
            ]
            4 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">According to Wilcoxon rank-sum test&#46;</p>"
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            5 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "f"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">According to paired <span class="elsevierStyleItalic">t</span>-tests&#46;</p> <p class="elsevierStyleNotepara" id="npar0035"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered significant&#46;</p>"
            ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Demographic&#44; clinical and biochemical data of the of the study population&#46;</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Data are presented as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviations &#40;x<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41; or as median with range&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group I<br>&#40;debut&#47;relapse&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group II<br>&#40;remission&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group III<br>&#40;control&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><br>&#40;groups I&#8211;III&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><br>&#40;group I&#8211;II&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IVC diameter inspiration&#47;BSA<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">b</span></a> &#40;mm&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;02 &#40;0&#46;58&#8211;10&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;92 &#40;0&#46;50&#8211;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;66 &#40;0&#46;22&#8211;4&#46;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;012<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;799<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IVC diameter expiration&#47;BSA &#40;mm&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;745<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;727<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;948<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;782<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;896<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">OH &#40;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;5 &#40;0&#46;63&#8211;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;3 &#40;&#8722;0&#46;5 to 0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;1 &#40;&#8722;1&#46;0 to 0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rel OH &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;9&#46;8&#8211;35&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;8&#46;6 &#40;&#8722;37 to 1&#46;70&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TBW&#47;BSA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;84 &#40;11&#46;6&#8211;17&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;8 &#40;10&#46;9&#8211;18&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;60 &#40;6&#46;94&#8211;10&#46;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;79 &#40;4&#46;69&#8211;7&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;5 &#40;4&#46;7&#8211;7&#46;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;532<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ECW&#47;ICW&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;42 &#40;0&#46;38&#8211;0&#46;45&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
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                  """
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              "identificador" => "tblfn0035"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Data shown as median values with range&#44; because of the non-normality of data according to the Shapiro&#8211;Wilk test&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0040"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0045">According to independent sample <span class="elsevierStyleItalic">t</span> test&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0045"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0050">According to Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46;</p>"
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            3 => array:3 [
              "identificador" => "tblfn0050"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0055">According to Wilcoxon rank-sum test&#46;</p>"
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            4 => array:3 [
              "identificador" => "tblfn0055"
              "etiqueta" => "f"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0060">According to paired <span class="elsevierStyleItalic">t</span>-tests&#46;</p> <p class="elsevierStyleNotepara" id="npar0065"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered significant <span class="elsevierStyleItalic">p</span> value of &#60;0&#46;05 &#40;controls vs&#46; patients&#41;&#46;</p> <p class="elsevierStyleNotepara" id="npar0070">OH&#58; Absolute fluid overload &#40;AFO&#41;&#46;</p> <p class="elsevierStyleNotepara" id="npar0075">Rel OH&#58; relative fluid overload &#40;RFO&#41; is defined as the AFO to ECW ratio&#46;</p> <p class="elsevierStyleNotepara" id="npar0080">ECW&#58; extracellular water&#46;</p> <p class="elsevierStyleNotepara" id="npar0085">ICW&#58; intracellular water&#46;</p> <p class="elsevierStyleNotepara" id="npar0090">TBW&#58; total body water&#46;</p> <p class="elsevierStyleNotepara" id="npar0095">E&#47;I&#58; ECW&#47;ICW&#46;</p>"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Assessment of ECW And Fluid Status in Study Population&#46;</p>"
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      ]
    ]
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                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
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                          "autores" => array:4 [
                            0 => "M&#46; Nash"
                            1 => "C&#46; Edelmann"
                            2 => "J&#46; Bernstein"
                            3 => "H&#46; Barnett"
                          ]
                        ]
                      ]
                    ]
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                        "titulo" => "The nephrotic syndrome in pediatric kidney disease"
                        "paginaInicial" => "1247"
                        "paginaFinal" => "1290"
                        "serieFecha" => "1978"
                      ]
                    ]
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                          "autores" => array:1 [
                            0 => "G&#46;C&#46; Arneil"
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                    0 => array:1 [
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                        "titulo" => "Management of the nephrotic syndrome in the child in clinical pediatric nephrology"
                        "paginaInicial" => "146"
                        "paginaFinal" => "172"
                        "serieFecha" => "1976"
                      ]
                    ]
                  ]
                ]
              ]
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            2 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sodium homeostasis in acute glomerulonephritis and nephrotic syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Contrib Nephrol"
                        "fecha" => "1980"
                        "volumen" => "23"
                        "paginaInicial" => "181"
                        "paginaFinal" => "203"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7002449"
                            "web" => "Medline"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Understanding the nephrotic syndrome&#58; what&#39;s new in a decade&#63;"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46;J&#46; Dohout-Mees"
                            1 => "H&#46;A&#46; Koomans"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                        "tituloSerie" => "Nephron"
                        "fecha" => "1995"
                        "volumen" => "70"
                        "paginaInicial" => "1"
                        "paginaFinal" => "10"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7617085"
                            "web" => "Medline"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Over- or underfill&#58; not all nephrotic states are created equal"
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46; Bockenhauer"
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                      "doi" => "10.1007/s00467-013-2435-6"
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                        "tituloSerie" => "Pediatr Nephrol"
                        "fecha" => "2013"
                        "volumen" => "28"
                        "paginaInicial" => "1153"
                        "paginaFinal" => "1156"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Blood volume&#44; colloid osmotic pressure and F-cell ratio in children with the nephrotic syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Vande Walle"
                            1 => "R&#46; Donckerwolcke"
                            2 => "P&#46; Boer"
                            3 => "H&#46;W&#46; van Isselt"
                            4 => "H&#46;A&#46; Koomans"
                            5 => "J&#46;A&#46; Joles"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Kidney Int"
                        "fecha" => "1996"
                        "volumen" => "49"
                        "paginaInicial" => "1471"
                        "paginaFinal" => "1477"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8731116"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Plasma and blood volumes in patients with the nephrotic syndrome"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;B&#46; Geers"
                            1 => "H&#46;A&#46; Koomans"
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        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0190" class="elsevierStylePara elsevierViewall">We thank those of our patients and clinical colleagues who have supported this research&#46;</p> <p id="par0195" class="elsevierStylePara elsevierViewall">We presented this study as a poster presentation in the 47th ESPN Congress in Porto&#44; Portugal&#44; September 18&#8211;20&#44; 2014 &#40;p206&#41;&#46; This study was supported by <span class="elsevierStyleGrantSponsor" id="gs3">Ondokuz Mayis University</span> Department of Scientific Research Projects&#46;</p>"
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Información del artículo
ISSN: 02116995
Idioma original: Inglés
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